Clinical outcomes of venoarterial extracorporeal life support in 462 patients: Single-center experience.

This study aims to investigate the outcomes of venoarterial extracorporeal life support (VA-ECLS) in a large single-center patient cohort regarding survival and adverse events. Between June 2009 and March 2019, 462 consecutive patients received VA-ECLS. The mean age was 66.2 ± 11.9 years. Two patient groups were identified: Group 1-patients with ECLS due to postcardiotomy shock (PCS) after cardiac surgery (PCS, n = 357); Group 2-patients with ECLS due to cardiogenic shock (CS) without previous surgery (nonPCS, n = 105). The primary end point was overall in-hospital survival, while secondary end points were adverse events during the study period. Overall, the in-hospital survival rate was 26%. There was no statistically significant difference between the groups: 26.3% for PCS and 24.8% for nonPCS, respectively (P > .05). Weaning from VA-ECLS was possible in 44.3% for PCS and in 29.5% for nonPCS (P = .004). The strong predictors of overall mortality were postoperative hepatic dysfunction (OR = 14.362, 95%CI = 1.948-105.858), cardiopulmonary resuscitation > 30 minutes (OR = 6.301, 95%CI = 1.488-26.673), bleeding with a need for revision (OR = 2.123, 95%CI = 1.343-3.355), and previous sternotomy (OR = 2.077, 95%CI = 1.021-4.223). Despite its low survival rates, VA-ECLS therapy is the last resort and the only lifesaving option for patients in refractory CS. In contrast, there is still a lack of evidence for VA-ECLS in PCS patients. Future studies are warranted to evaluate the outcomes of VA-ECLS therapy after cardiac surgery.

Another Role for Angiotensin II?: Vasopressin-Refractory Shock After Pheochromocytoma Resection: A Case Report.

A patient presented with multiple unrelated tumors and was found to have a small but functional adrenal pheochromocytoma. After pheochromocytoma resection, shock developed unresponsive to vasopressin in recommended doses (0.04 U/min infusion plus repeated 1-U boluses) but responded dramatically to an angiotensin II infusion (20 ng/kg/min) with a mean arterial pressure >100 mm Hg. The patient's blood pressure was maintained for 42 hours postoperatively with an infusion rate that ranged from 2 to 38 ng/kg/min. Because vasopressin may not always be effective for postresection shock in people with pheochromocytomas, angiotensin II may prove to be an effective alternative.

Nutritional Support in Postcardiotomy Shock Extracorporeal Membrane Oxygenation Patients: A Prospective, Observational Study.

BACKGROUND: Despite the 6000 patients treated with extracorporeal membrane oxygenation (ECMO) annually, there is a paucity of data regarding the nutritional management of these patients. MATERIALS AND METHODS: We performed a prospective, observational study of nutrition in postcardiotomy shock patients at our institution. Over a 3.5-year study period, we identified 50 ECMO patients and 225 non-ECMO patients. We identified type, amount, duration, and disruption of nutritional delivery by cohort. The primary outcome was percent of caloric goal met, and secondary outcome was gastrointestinal complications. RESULTS: ECMO patients met less of their caloric (29% versus 40%, P = 0.017) and protein goals (34% versus 55%, P < 0.001) compared with non-ECMO patients. Tube feeds were administered more slowly (26 versus 37 mL/h, P < 0.001) and held for longer (8.3 versus 4.5 h/d, P < 0.001) in ECMO patients because of procedures (60%) and high-dose pressors (20% versus 7%, P < 0.001). Multivariate analysis demonstrated that ECMO decreased caloric intake by 14%, with no detected increased risk of gastrointestinal complications. CONCLUSIONS: -ECMO patients received significantly less nutrition support compared with a non-ECMO population. Tube feed hold deficits could potentially be avoided by utilizing postpyloric tubes to feed through procedures, by eliminating holds for vasopressors/inotropes in hemodynamically stable patients, or by establishing volume-based feeding protocols. Further clinical studies are needed to establish efficacy of these interventions and to understand the impact of nutrition on outcomes in ECMO patients.

Vasopressin therapy in cardiac surgery.

BACKGROUND: Arginine vasopressin (AVP) is a naturally occurring peptide with diverse effects mediated through selective V1 and V2 receptors. About 10% of patients undergoing cardiopulmonary bypass develop postoperative vasodilatory shock requiring high-dose catecholamines. We sought to examine the role of AVP therapy in cardiac surgery. METHODS: A search of Medline was conducted through September 2018 using key words and medical subject headings (MeSH) relating to AVP, copeptin, and cardiac surgery. A systematic review was performed on articles as they pertained to AVP for use as a vasopressor after cardiovascular surgery complicated by vasodilatory shock. RESULTS: A relative or absolute deficiency of Arginine vasopressin is associated with vasodilatory shock after cardiopulmonary bypass. Physiologic replacement with exogenous Arginine vasopressin results in significant increases in systemic vascular resistance and mean arterial pressure with decreased requirements of catecholamines. At doses of <0.1 U/min Arginine vasopressin is safe with very few adverse effects. CONCLUSION: Post-cardiopulmonary bypass vasodilatory shock is largely due to a relative deficiency of Arginine vasopressin. Exogenous administration of low-dose Arginine vasopressin alone or in combination with traditional catecholamines is a safe and effective way to manage this type of vasodilatory shock.

The incidence and impact of implantable cardioverter defibrillator shocks in the last phase of life: An integrated review.

BACKGROUND: Although the implantable cardioverter defibrillator is successful in terminating life threatening arrhythmias, it might give unwanted shocks in the last phase of life if not deactivated in a timely manner. AIMS: This integrated review aimed to provide an overview of studies reporting on implantable cardioverter defibrillator shock incidence and impact in the last phase of life. METHODS AND RESULTS: We systematically searched five electronic databases. Studies reporting on the incidence and/or impact of implantable cardioverter defibrillator shocks in the last month of life were included. Fifteen studies were included. Two American studies published in 1996 and 1998 reported on the incidence of shocks in patients who died non-suddenly: incidences were 24% and 33%, respectively, in the last 24 hours, and 7% and 14%, respectively, in the last hour of life. Six American studies and one Danish study published between 1991-1999 reported on patients dying suddenly: incidences were 41% and 68% in the last 24 hours and 22-66% in the last hour. Four American studies and two Swedish studies published between 2004-2015 did not distinguish the cause of death: incidences were 17-32% in the last month, 3-32% in the last 24 hours, and 8% and 31% in the last hour of life. Three American studies published between 2004-2011 reported that shocks in dying patients are painful and distressing for patients, and distressing for relatives and professional caregivers. CONCLUSION: If the implantable cardioverter defibrillator is not deactivated in a timely manner, a potentially significant proportion of implantable cardioverter defibrillator patients experience painful and distressing shocks in their last phase of life.

Monitoring modalities and assessment of fluid status: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Fluid administration in critically ill surgical patients must be closely monitored to avoid complications. Resuscitation guided by invasive methods are not consistently associated with improved outcomes. As such, there has been increased use of focused ultrasound and Arterial Pulse Waveform Analysis (APWA) to monitor and aid resuscitation. An assessment of these methods using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework is presented. METHODS: A subsection of the Surgical Critical Care Task Force of the Practice Management Guideline Committee of EAST conducted two systematic reviews to address the use of focused ultrasound and APWA in surgical patients being evaluated for shock. Six population, intervention, comparator, and outcome (PICO) questions were generated. Critical outcomes were prediction of fluid responsiveness, reductions in organ failures or complications and mortality. Forest plots were generated for summary data and GRADE methodology was used to assess for quality of the evidence. Reviews are registered in PROSPERO, the International Prospective Register of Systematic Reviews (42015032402 and 42015032530). RESULTS: Twelve focused ultrasound studies and 20 APWA investigations met inclusion criteria. The appropriateness of focused ultrasound or APWA-based protocols to predict fluid responsiveness varied widely by study groups. Results were mixed in the one focused ultrasound study and 9 APWA studies addressing reductions in organ failures or complications. There was no mortality advantage of either modality versus standard care. Quality of the evidence was considered very low to low across all PICO questions. CONCLUSION: Focused ultrasound and APWA compare favorably to standard methods of evaluation but only in specific clinical settings. Therefore, conditional recommendations are made for the use of these modalities in surgical patients being evaluated for shock. LEVEL OF EVIDENCE: Systematic Review, level II.

The role of extracorporeal membrane oxygenator therapy in the setting of Type A aortic dissection.

BACKGROUND AND AIM: Patients presenting with type A aortic dissection (TAAD) present with a wide clinical spectrum ranging from hemodynamic stability to multiorgan malperfusion with cardiovascular collapse. Extracorporeal membrane oxygenator (ECMO) therapy is increasingly being utilized as salvage therapy in patients with acute cardiopulmonary failure and for post-cardiotomy shock. We sought to determine the utility of ECMO implementation post-TAAD repair. METHODS: The Pennsylvania Health Care Cost Containment Council (PHC4) database, maintained by an independently functioning state agency, was retrospectively reviewed from 2004 to 2014. Patients with a primary diagnosis of aortic dissection requiring ECMO support during the same hospital visit were included in the analysis. RESULTS: Thirty-nine patients were identified with diagnosis/procedure codes for TAAD repair and ECMO, of which four patients did not undergo TAAD repair. Of the remaining 35, 31 patients underwent open repair, and four patients underwent TEVAR. ECMO was instituted on the same day of TAAD surgery in 27 (69.2%) patients, and on post-operative day >1 in eight (20.5%) patients. Overall mortality in patients who were on ECMO the same day was 88.9% and 87.5% when it was done after the first post-operative day. All four patients with TAAD who underwent ECMO only died. Median time from ECMO implantation to death was 1.0 day. CONCLUSIONS: Requirement for ECMO support in acute aortic dissection is associated with extremely high mortality irrespective of when the intervention is performed.

Early High-Volume Hemofiltration versus Standard Care for Post-Cardiac Surgery Shock. The HEROICS Study.

RATIONALE: Post-cardiac surgery shock is associated with high morbidity and mortality. By removing toxins and proinflammatory mediators and correcting metabolic acidosis, high-volume hemofiltration (HVHF) might halt the vicious circle leading to death by improving myocardial performance and reducing vasopressor dependence. OBJECTIVES: To determine whether early HVHF decreases all-cause mortality 30 days after randomization. METHODS: This prospective, multicenter randomized controlled trial included patients with severe shock requiring high-dose catecholamines 3-24 hours post-cardiac surgery who were randomized to early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous venovenous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function, or conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury. MEASUREMENTS AND MAIN RESULTS: On Day 30, 40 of 112 (36%) HVHF and 40 of 112 (36%) control subjects (odds ratio, 1.00; 95% confidence interval, 0.64-1.56; P = 1.00) had died; only 57% of the control subjects had received renal-replacement therapy. Between-group survivors' Day-60, Day-90, intensive care unit, and in-hospital mortality rates, Day-30 ventilator-free days, and renal function recovery were comparable. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia. CONCLUSIONS: For patients with post-cardiac surgery shock requiring high-dose catecholamines, the early HVHF onset for 48 hours, followed by standard volume until resolution of shock and recovery of renal function, did not lower Day-30 mortality and did not impact other important patient-centered outcomes compared with a conservative strategy with delayed CVVHDF initiation only for patients with persistent, severe acute kidney injury. Clinical trial registered with www.clinicaltrials.gov (NCT 01077349).

Catastrophic venous air embolism during craniotomy in the supine position: the bleeding pattern as a warning sign?

Venous air embolism is a serious complication during a neurosurgical procedure. Here is a case of a massive venous air embolism causing cardiac arrest in the supine position surgery. Identifying the alternative inflation and collapse of the sinus and taking emergency measures to avoid catastrophic result are important.

Multidisciplinary mechanical supports improve outcome in a shock patient with cardiac amyloidosis: a case report.

Shock patients with restrictive cardiomyopathy due to cardiac amyloidosis are refractory to medical treatment. Here, we report a case of early initiation of intra-aortic balloon pumping (IABP) in a patient with cardiac amyloidosis who developed postoperative shock. Continuous hemodiafiltration was also applied to control circulating fluid volume. The mechanical treatments allowed reduction of the doses of catecholamine and diuretics and resulted in full recovery. It is reasonable to initiate IABP and hemofiltration dialysis during the early stages for the appropriate control of hemodynamics and fluid in shock patients with cardiac amyloidosis.

The response to methylene blue in patients with severe hypotension during liver transplantation.

Methylene blue is a useful therapy for catecholamine-resistant vasoplegic shock. Three cases of methylene blue administration for the treatment of catecholamine-resistant hypotension during orthotopic liver transplantation are presented.

Occult hypoperfusion--should the military surgeon care?

The treatment of traumatic shock has changed unrecognizably over the past decade as the combination of targeted research and lessons learnt from conflict have combined with a common goal. The term damage control resuscitation has emerged as the most likely strategy to treat the underlying cause, restore normal physiology and ultimately return to normal function. However, there is still a great deal that we do not understand as to the underlying mechanisms which control the traumatic shock process. Military surgeons have an integral part to play at every step of this process. Their role does not end once the initial damage control surgery is complete and indeed the decisions that are made during the initial resuscitation will have an effect on all future stages of care. The patient's physiology is delicately balanced with the possibility that a wrong treatment decision may be a fatal one. It is essential that the surgeon has an understanding of these underlying processes so that an informed decision can be made at the right time.